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by Robin Cook

  “It involved the technical equipment,” Dr. Wykoff said. She spoke calmly, to Michael’s relief, and then paused to stare off into the middle distance.

  “You mean with the anesthesia machine?” Michael said. He tightened his grip on Lynn’s arm to keep her quiet. From the sounds of her breathing he sensed she was about to say something.

  “Not the machine per se,” Dr. Wykoff said. “But with the monitor. I happened to see it only because I was concentrating on looking at the monitor at the moment it occurred. It was when the surgeon began drilling into the tibia. I wanted to make sure that the depth of analgesia was adequate. Since the periosteum has a lot of pain fibers, I was watching the vitals closely.”

  “And what happened?” Michael asked.

  “Let me show you,” Dr. Wykoff said. “It is actually part of the anesthesia record.” Dr. Wykoff directed her attention to the screen of the computer terminal and began punching in commands.

  While she was busy, Michael gave Lynn’s arm an extra squeeze to get her attention. “Cool it, girl!” he mouthed along with a harsh expression when she looked at him. He was serious. Lynn responded by trying to get her arm back, but Michael would not let go. Under his breath he said, “Let me do the talking! You’re going to get us thrown in jail if you keep up! Seriously!”

  “All right, here it is,” Dr. Wykoff said, interrupting. The doctor angled the monitor’s screen more toward the students. It was the image of the anesthesia machine–generated record in graphic form of what had been on the monitor during the case, including blood pressure, pulse, ECG, blood oxygenation, end tidal CO2, expired tidal volume, and body temperature. Michael and Lynn stood up to get a better view, even though it was what they had already seen in Carl’s chart.

  “Look closely,” Dr. Wykoff said. She enlarged the image and used a pen as a pointer. “Here is when the oxygenation fell from close to one hundred percent down to ninety-two. It’s at eight-thirty-nine, or sixty-one minutes into the operation. That was when the alarm sounded. And you can see the ECG simultaneously shows tenting of the T waves, suggesting the heart isn’t getting adequate oxygen. Now, that doesn’t make sense. An oxygenation saturation of ninety-two percent shouldn’t cause the immediate appearance of T waves in a normal, healthy heart. Also there’s no change in any of the other parameters, which would certainly happen if there was low enough oxygen to cause brain damage.”

  “We saw that when we looked at the chart,” Michael said.

  “It’s hard not to see it,” Dr. Wykoff said. “It jumps out at you, since the oxygenation tracing was essentially a straight-line until that instant. But the fall is not what I want to show you.” She used the cursor to move back along the oxygenation tracing to fifty-two minutes into the operation, where there was a slight vertical blip upward. “Do you see this?”

  “I do,” Michael said. “It is a sudden notch upward, whereas the O2 tracing otherwise is like a flat, smooth sine wave, varying between ninety-seven and one hundred percent. What does it mean?”

  “Probably nothing,” Dr. Wykoff admitted. “But notice the notch upward occurred with all the tracings on the monitor: blood pressure, oxygen saturation, everything. It scared me when it happened because I was actually closely watching the pulse rate. If a patient feels any pain when the surgeon drills into the periosteum, the pulse rate goes up, meaning the anesthesia is light. Well, the pulse rate didn’t go up. Instead, while I was watching, the whole monitor blinked at the precise moment the slight vertical jump appeared.”

  “Blinked?” Michael repeated. “Does that happen often?”

  “Not in my experience,” Dr. Wykoff said. “But then again we anesthesiologists don’t spend a lot of time staring at the monitor. None of us does unless there is a specific reason. When it happened, it scared me, which is why I remember it.”

  “Why did it scare you?” Michael asked. It seemed inconsequential to him.

  “What scared me was the worry of losing the feed from all my sensors, meaning I would be without electronic monitoring. I was relieved when it didn’t blink again.”

  “You had never seen anything like that before?” Michael asked. He bent close to look at the image as the anesthesiologist magnified the section. To him it still looked trivial.

  “No, I haven’t,” Dr. Wykoff said. “But that doesn’t mean it doesn’t happen. Maybe it happens often. I don’t know. It is such a small change. Electronics are not my thing. But it can’t have any significance since all the vital signs, as you can plainly see, stayed completely normal right up to the moment the oxygenation alarm sounded. As I said, the reason I remember it is that we anesthesiologists are accustomed to continuous electronic monitoring. Giving anesthesia without it would be like flying an airplane blind.”

  “Do you see it?” Michael asked Lynn.

  “Of course I see it,” Lynn snapped.

  Michael rolled his eyes and again tightened the grip he had on Lynn’s arm as he made her step back from the monitor. He regretted trying to bring her back into the conversation for fear she would ruin the rapport that had been established with Dr. Wykoff and maybe get them in trouble after all. He knew it was time to leave. “We want to thank you, Dr. Wykoff, for—” He didn’t get to finish. The door to the corridor burst open, and a man charged into the room.

  Yanking off a surgical face mask, the newcomer headed for a computer terminal, but, catching sight of the others, he stopped short. It was apparent he had assumed the room to be empty. He was a powerful-looking, golf-tanned Caucasian man dressed in scrubs. Adding to his physical stature were big hands and muscular forearms. At first his expression was one of perplexity, but it quickly changed to aggravation. He looked back and forth between Michael and Lynn. Both knew who he was from their third-year surgery rotation. He was Dr. Benton Rhodes, the volatile, New Zealand–born chief of anesthesia who was renowned for having little love for medical students.

  “We were just leaving,” Michael said quickly. He turned back to Dr. Wykoff. “Thanks for your time and willingness to talk to us about such a disturbing case. We appreciate it.”

  “What case?” Dr. Rhodes demanded with his Anzac accent.

  “Carl Vandermeer,” Lynn said defiantly.

  “Vandermeer?” Dr. Rhodes repeated as if shocked. “Who are you two?”

  “We’re fourth-year medical students,” Michael said quickly, urging Lynn toward the door. She resisted, fanning his fear that this unexpected encounter might not end well.

  “What are your names?” Dr. Rhodes demanded.

  “I’m Lynn Peirce and this is Michael Pender.”

  Dr. Benton turned to Dr. Wykoff and shouted angrily in apparent disbelief: “You were discussing the Vandermeer case with these medical students? I don’t understand. Yesterday afternoon we were warned by the hospital counsel not to discuss the case with anyone.”

  “They are interested in hospital-acquired morbidity,” Dr. Wykoff explained. “It is an important and legitimate issue, and they are our medical students.”

  “I couldn’t care less who they are,” Dr. Rhodes continued to shout. “The case is not to be discussed with anyone, period!” Then, turning to the students, he snapped, “And I want you two out of here. But be warned! I am going to be giving your names to the hospital counsel. The order not to discuss the case with anyone now includes you. Don’t talk about it with anyone: friends, family, fellow students, whatever. Doing so will jeopardize your status as medical students. Do you understand? It is hugely important that I am very clear about this.”

  “We understand,” Michael said, dragging Lynn toward the door. He wanted to get her out of the room before she said anything else.

  20.

  Tuesday, April 7, 10:05 A.M.

  As the door to the anesthesia office closed behind them, Michael and Lynn heard Dr. Rhodes’s tirade continue. The man was clearly beside himself with rage at Wykoff.

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p; “Talk about burning bridges and making enemies,” Michael said as they headed down the central corridor. “That turned out to be a big-time fuckup.”

  “It wasn’t our fault,” Lynn said, keeping her voice down as they passed people. “It was just bad luck that Rhodes showed up. Everything had been going fine until then.”

  “One way or another, we’re not going to be able to go back to Dr. Wykoff. Of course it might have happened anyway, considering the way you were talking to her.”

  “What is that supposed to mean?” Lynn said, taking offense.

  “You were accusing her of screwing up, just like I told you not to do. That ain’t the way to keep your options open, girl. Take it from me. The reason that I never got shot or that I’m not in prison is that I learned early not to piss people off. The way you were acting, I’m surprised we got as much out of Dr.Wykoff as we did.”

  “I’m the one who is pissed. I didn’t feel like giving her any slack.”

  “And you certainly didn’t.”

  “I still think she is hiding something. She has to have done something wrong. I’m sorry, but that’s the way I see it.”

  “Well, I don’t,” Michael said. “My take is that she is hurting over the case and has no idea what happened. She wouldn’t have gone on about that blip. Electronic equipment has little burps like that, particularly video and sensory feed. It’s called a frame offset. My take is that she’s almost as desperate as you are to find out what the hell happened.”

  “We are going to have to agree to disagree,” Lynn said. “And I’m bummed out we weren’t able to bring up either of the other cases, as similar as they seem to be. I also wanted to ask her what she thought of the idea of an anesthetic causing the protein abnormality Morrison has. And the fever she and Carl have. Hell, I’ve got a lot of questions that need answering. I think we should try to meet with the other anesthesiologists. Do you remember who did Ashanti’s case?”

  Michael hated and pulled Lynn to a stop in the process. They were just abreast of the Surgical Pathology Department. He looked at her with disbelief. “You’re joking, of course. Tell me you’re joking!”

  “No, I’m not joking. I think we should talk with the other anesthesiologists. Maybe they all made the same mistake. It could be the only way to find out. I’m not convinced they talk to each other when something like this happens. In that sense you are right: they are all defensive.”

  “First of all, I don’t remember who the anesthesiologist was for Ashanti. But if I did, I wouldn’t tell you. You heard how pissed Dr. Rhodes was that we were discussing Carl with Wykoff. If he finds out you’re even thinking about talking with the other anesthesiologists, he’ll go berserk. He could get our asses kicked out of school. Wouldn’t that be nice now that we are within sight of graduating? I’m sure that a big reason he was so pissed is because Carl represents the third case.”

  “Are you finished?”

  “Yes, I’m finished. Let’s get changed and get out of here.”

  They started walking again.

  “I think we were lucky to get away pretty much unscathed,” Michael said.

  “That’s not a given,” Lynn said. “What do you think the chances are that either Wykoff or Rhodes might say something to the nurses in the neuro ICU? It might occur to them to ask how it was we were able to look at Carl’s chart. If they do, it would be bad. We wouldn’t be able to go back, and I wouldn’t be able to follow Carl much less find out how this happened.”

  “I think it’s hard to say what they might do. If they think about informing the nurses, they might. I believe it will come down to that, but in our favor, they have a lot on their minds. I’m sure they are running scared about a possibility of a serious lawsuit.”

  “I don’t think Carl’s parents will sue,” Lynn said.

  “I don’t think you can say that. With the dad being a lawyer—a litigator, no less—I personally think the chances are good. One of the malpractice guys will talk them into doing it supposedly as a way of keeping other people from falling victim to the same fate. I’m sure fear of a big lawsuit is why the hospital counsel is so concerned.”

  They reached the main elevators and paused before going into the surgical lounge. Michael checked his watch. “We’re going to have to make tracks to get to the derm clinic. They are not going to be happy we missed the lecture. Thank God we can use the ER as an excuse. Listen, I’ll meet you out here after we change back into our street clothes.”

  “I’m not going to any clinic,” Lynn said. “Particularly a derm clinic. In my state of mind there’s no way I could concentrate on looking at pimples and rashes.”

  “What are you going to do? You’re not thinking of going back to talk to any anesthesiologists, are you?”

  “No! I’ve got to make myself sleep, at least a few hours. I know I’m not thinking right, and I have a shitload of studying I want to get done. I need to learn more about those monoclonal gammopathies and multiple myeloma.”

  “Suit yourself, but I’m going to the clinic. I don’t want to risk pissing off the admin at this point so close to graduation, especially with Rhodes possibly on our case.”

  “Be real! You really think they might deny graduation from missing a few crummy specialty lectures and clinics?”

  “Who knows? What I do know is that it ain’t worth the risk. If there is a sign-in for attendance, I’ll add your name.”

  “Thanks, bro. One other thing! Can I look at that photo of Ashanti’s anesthesia record on your desktop computer?”

  Michael eyed Lynn and hesitated, as if debating. “I’d have to give you my room key. You might copy it and come in and molest me.”

  “As tempting as that may be, I’ll give you my word to hold myself back. And I promise not to disturb your stash of smack.”

  “You better not! All right, then, I’ll meet you out here at the elevators in five.”

  • • •

  While Michael was changing back into his street clothes, he found himself wondering what would have happened had he not accompanied Lynn to meet Wykoff. As bad as it had turned out, he was certain it would have been much worse if she had been on her own. As he saw it, no matter what he had said, she needed close monitoring, as she’d copped an attitude Michael was certain was destined to get her in real trouble and possibly him, too. Yet he could understand and sympathize. If what happened to Carl had happened to his girlfriend, Kianna Young, he’d be a basket case, too.

  When Michael got back out to the elevator lobby, he was moderately surprised that Lynn was already there. He thought he had changed quickly and had expected to have to wait. He handed her his room key and said: “Would you mind making the bed and cleaning the bathroom while you are in there?”

  “Fat chance, you male chauvinist,” Lynn said as she snatched the key. “I’m going to e-mail the photo of Ashanti’s record to myself and that’s it. Another request! Would you e-mail me the photos you took of Carl’s and Morrison’s records? Then I’ll have all three. By comparing them, maybe I’ll be able to find something unexpected.”

  “I think the first thing you need to do is get some sleep.”

  “Thank you, Doctor. Meanwhile do the e-mails.”

  “Yes, ma’am,” Michael said, saluting.

  21.

  Tuesday, April 7, 10:15 A.M.

  Benton Rhodes slammed the door to his private office with such force that some of his framed diplomas on the walls tilted, requiring him to walk around and straighten them. He imagined that the concussive sound had probably jolted the Anesthesia Department secretary sitting at her desk just outside. She had been listening to dictation and typing on her monitor when he had walked by, and hadn’t seen him. Yet if he’d startled her, he didn’t feel the slightest bit guilty. When he was enraged, he often took it out on anybody and anything. The idea that he’d scared the secretary actually calmed him to a degree.
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  He was still dressed in scrubs, even though he had left the OR and descended to the admin area, where most of the department heads had their formal offices. But before he had left the floor, he’d ducked into the locker room to get his phone. Sitting down at his desk, he pulled it out of his pocket and went into his contacts. Then he paused. He didn’t know whom to call first about this latest stupid screwup.

  For the life of him, Benton couldn’t understand how people could be so smart in some things and so stupid in others, which was why he had yelled at Sandra Wykoff. As dedicated an anesthesiologist as she was, he couldn’t comprehend how she could have misinterpreted the instructions from Bob Hartley, the hospital counsel, about not discussing the Vandermeer case with anyone. The lawyer couldn’t have been any clearer. Not discussing it with anyone meant no one, period. Especially not a couple of medical students rummaging around for a cause to make a name for themselves. “Hospital-acquired morbidity,” my ass, he thought glumly. The next thing they might do is put on Twitter or Facebook what they believed to be sage observations about the case. God, it would be a disaster!

  Drumming his fingers on his desk, Benton thought that running the Mason-Dixon Medical Center’s Anesthesia Department was turning out to be more of a bother than he had bargained for. When he’d been recruited five years previously at the age of sixty-four, he had been in charge of the anesthesia department of a much larger, Ivy League center that did twice the surgical volume and had an anesthesiology residency program to boot. Yet it had somehow seemed easier in New England and without the anxiety he was dealing with here in Charleston. It was the South, for God’s sake, where he’d heard people were supposed to laze around and sip mint juleps. His goal had been a semi-retirement to enjoy life. Unfortunately it was not working out that way.